Progress report on the implementation of the Behaviour Management review, October 2018.

Foreword by Pat Bergin, Director of Oberstown.

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FOREWORD

Oberstown Children Detention Campus (Oberstown) provides safe and secure care and education to

young people under 18 years referred by the courts. Oberstown’s ethos is drawn from the Children Act

2001, which sets out the requirements to ensure that young people receive care, education, healthcare,

work on offending behaviour and preparation for release (known as CEHOP). Although an amalgamation

of three former detention schools has been underway since 2014, these came together legally in June

2016 to form the Oberstown Campus, reflecting a single model of care based on the CEHOP framework.

During this period, responsibility for 16 and 17 year olds was given to Oberstown, as these young people

were previously remanded and sentenced to the prison estate. The challenges associated with this

change process came to the fore in the Summer/Autumn of 2016 when the Campus experienced a

particular period of instability, culminating in industrial action and associated challenges. In order to

resolve these difficulties, agreement was reached with staff representatives called the Forde Framework.

As part of this agreement, a number of reviews were carried out, commissioned by the Director, to

explore security, health and safety and behaviour management issues. All of these reports completed

during 2016 and early 2017 were shared as appropriate with the relevant stakeholders and were also

incorporated into the work of the Review Implementation Group, set up by the Minister for Children and

Youth Affairs, designed to provide a framework for their collective implementation. 1

This report on aspects of behaviour management on the Campus was commissioned by the Director in

this context, and was undertaken by Professor Derek Perkins and Dr Margaret O’Rourke, two

psychologists with particular clinical experience of managing behaviour in secure settings. The review was

completed in early 2017 and in addition to this report, the process involved dialogue and engagement

with Campus staff and management which was designed to ensure that the Campus was supported to

move forward in a constructive and inclusive way in the interests of young people and staff. The report

was circulated to staff, Board of Management and the Department of Children and Youth Affairs for their

information and consideration in 2017.

The report sets out the many challenges experienced by the Campus and as such represents a snapshot in

time and of certain issues and perspectives. It is not intended to be, nor could it be, given the short

1 A Review Implementation Group was established in March 2017 to oversee the implementation of several reviews carried out in Oberstown during 2016/2017. All reports from the RIG available here

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timeframe of the review, a comprehensive account of all matters associated with the Campus.

Nonetheless, it sets out important learning for the Campus by identifying the challenges and setting out

clear, practical recommendations necessary to bring about the necessary improvements in approach to

behaviour management.

There has been substantial progress already made in the implementation of these recommendations. In

general terms, these achievements are set out of in the Campus Annual Report for 2012-2016 and again

in the more recent Annual Report for 2016 – 2017, available on the Campus website. It is also evident in

the two reports of the full inspections carried by HIQA inspectors, appointed by the Minister to inspect

the Campus across a range of standards, in March 2017 and again in March 2018. These reports provide

objective and robust evidence that progress is in being made to ensure that Oberstown provides the best

possible care to young people referred to us by the courts.

The highlights of the progress made include:

Substantial progress in the implementation of the “CEHOP framework” which addresses the care

and educational needs of young people, while ensuring the health and wellbeing services are

delivered on the Campus.

The Oberstown Strategic Plan, 2017 -2020 was approved by the Board of Management in

October of 2017. The five goals of the plan are to: Provide the best possible care for young

people; develop our people and organization; implement policies, procedures and standards

consistent with the best model of detention for young people; enhance communications aligned

to our values and mission; deliver robust governance at all levels and drive effective

accountability.

Placement planning continues to evolve for young people, which also incorporates addressing

offending behavior and preparing young people for their release from Campus.

Use of data to inform practice in Oberstown and also in the youth justice sector has substantial

progressed. In 2017 and 2018, the Campus collated information on the characteristics of young

people placed in the Campus in the first quarter of each year. The findings of these exercises

highlighted the vulnerability and significant needs of young people detained in Oberstown.

Reports on the data collated and findings are available at www.oberstown.com .

Engagement between staff representatives, Department of Children and Youth Affairs and the

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Crisis Prevention Institute on the use of MAPA (Management of Actual or Potential Aggression)2

and the implementation of the approved program was undertaken in 2017. Training and reviews

are now built into the delivery of this strand of managing behavior on campus with improved

practices evident in the management of young peoples’ behaviour.

Reviews of Critical Incidents are routinely undertaken through a process of after incident reviews

(AIR) which bring together staff involved in an incident to determine what worked well, what

areas of improvements are required and what actions are necessary.

A submission was made by the Director to the Policing Authority on the Future of Policing in

Ireland. Delegates from the Commission visited Oberstown and met with young people to hear

their views for the Future of Policing in Ireland report. Formal engagement between An Gardai

Siochana and the Director took place in 2018 on the response to critical incidents on the campus.

Both services continue to work together to ensure safe and secure environment.

Director and campus senior management team are actively visible across the campus and engage

directly with staff and young people to ensure the campus is fulfilling its mission through the

implementation of the campus values.

To aid transparency and understanding about the operation of the Campus, this report is being published

together with an account that provides up to date information on the progress being made in the

implementation of the report’s recommendations. Accordingly, each recommendation is followed by a

section setting out the key measures adopted and the other information designed to bring the reader up

to date on the status of behavior management in Oberstown.

Director, Pat Bergin

October 2018

2For more information see: Crisis Prevention Institute, available at: https://www.crisisprevention.com/en-ie/Specialties/MAPA-

Management-of-Actual-or-Potential-Aggression

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BEHAVIOURAL MANAGEMENT REVIEW 2017

OBERSTOWN CHILDREN DETENTION CAMPUS

By Professor Derek Perkins and Dr Margaret O’Rourke Consultant Forensic Clinical Psychologists.

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ACKNOWLEGEMENTS

We are very grateful for the courteous, comprehensive and efficient way in which we were initially

briefed, relevant documentation was provided, and for the openness and co-operation of all staff with

whom we interacted. We are also extremely appreciative of the opportunities we had to spend time

talking with boys on different units, hearing of their experiences and suggestions.

SCOPE OF THE REVIEW

REASON FOR THE REPORT: This Behaviour Management review was requested by the Director of

Oberstown, Mr. Pat Bergin in January 2017. The brief was to review behaviour management policies,

procedures and practices used on the campus to determine if they are fit for purpose considering the

young people on remand and committal orders at the campus, and to issue a report with findings and

recommendations on seven domains as follows:

1. Early Intervention approaches

2. Routine Practices

3. Crisis responses

4. Use of Physical Intervention

5. Use of the Environment

6. Managing Violent Situation

7. Safety for Young People and staff

The review was requested and commenced in January 2017, along with separate Security and

Health & Safety reviews, all of which were agreed with the Trade Union as part of the Forde

process. A separate PPE report was also commissioned. All of these deal with contentious issues,

with the reviews serving to help Oberstown move forward.

SOURCES OF INFORMATION USED FOR THIS REVIEW

For the purposes of this review the following legislation, policies, procedures and documentation

were considered:

1) Children Act 2001, as amended

2) Criminal Justice Act 2006, Childcare (Amendment) Act 2007

3) Department of Children and Youth Affairs, Tackling Youth Crime – Youth Justice Action

Plan 2014-2018

4) Irish Penal Reform Trust, Detention of Children in Ireland: International Standards and

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Best Practice. 2009

5) Centre for Effective Services, Building Relationships with Young People in Oberstown to

Improve Pro-Social Outcomes. 2016

6) CPI Behaviour Management Policy and Procedures for Children Detention Schools – Irish

Youth Justice Service 2012

7) Oberstown Children’s Detention Campus, Critical Incident Management Plans 2016

8) Learner Booklets and Instructor Guide for Management of Actual and Potential

Aggression MAPA training courses. 2015

9) Lessons from the Literature – Building relationships with detained young people to

improve pro-social outcomes. Bamber, J. ,Brolly, C.,Mills,E. and Farrar,C. 2016

10) Internal Oberstown Policies, Procedures and Protocols relevant to Behaviour

Management and Business Continuity Plan 2016

In preparing this report we gathered information and opinions as follows, each person interviewed

having been given the purpose of our review, contemporaneous notes taken of all interviews, and

assurances of anonymity given if requested:

1) Interviews with Children detained at Oberstown within three units: these comprised

both group discussion and five individual discussions, involving approximately 20 boys in

total.

2) Interview with Principal Officer / Child Welfare Advisor, Department of Children and

Youth Affairs

3) Interviews with Unit Staff members and key workers (Experienced and New Staff)

4) Interviews with Unit Managers

5) Interview with Principal of the School

6) Interview with Clinical Nurse Manager 2

7) Interview with two MAPA Trainers

8) Interviews Senior Management Team members

9) Ongoing discussions with the Director Mr. Bergin and Deputy Director Ms. Timoney

throughout the review process

10) Consultation with members of the Assessment Consultation and Therapy Service (ACTS)

TUSLA

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SOME IMPORTANT POINTS ABOUT BEHAVIOUR MANAGEMENT

Good quality, safe, behaviour management requires clear, consistent and transparent rules and

routines that are modeled by service providers and are applied consistently and contingently to

behaviour.

Positive behaviour and pro-social outcomes depend on a number of factors, the most important

of which are a safe and enabling environment and the ability, willingness and opportunities of

young people to engage with the residential social care workers and their own care plan. This

requires a constant process of engagement and use of a range of approaches depending on the

risk, the needs of young people and other circumstances, from early intervention to routine

communication to specific interventions that deal with exceptional circumstances.

Young people at Oberstown have complex multiple needs and vulnerabilities, and behaviour is

often influenced by historical, clinical, dispositional and contextual factors such as anti-social

habits and behaviours, poor coping, immaturity, adverse life experience, trauma history, lack of

skill and/or experience in pro-social adult modeling, victimisation, mental health issues and

alcohol and/or substance misuse. These issues can be very challenging for care, education and

health staff and highlight the need effective for risk and case management, care /clinical

management, supervision of staff, mentoring and continuing professional development (CPD).

RELEVANT BACKGROUND

Reform of Youth Justice has been underway in Ireland since the enactment of the Children Act 2001. The

system is focused on the core principle of diversion, and young people who come into contact with the

law are diverted at every possible opportunity. Under section 96 of the Children Act 2001, detention

must be a measure of last resort. This means, that children who are remanded or sentenced to

Oberstown are amongst the most complex, challenging and difficult young offenders, presenting with

both one-off serious offences and significant histories of offending. The children may have a history of a

range of serious and persistent offences, including the most severe forms of interpersonal violence and

sexual offending. The children remanded or sentenced to Oberstown can range from 13-18, and often

have high cumulative lifetime adversity and multiple needs and vulnerabilities.

The Oberstown Campus is an amalgamation of three previously existing schools (Trinity, Oberstown

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Girls and Oberstown Boys) and an Assessment Centre, each with their own distinct philosophies of care

and management practices. The campus consists of nine units, eight currently operational, designed to

accommodate a maximum number of 82 children. The current license issued by the Minister for

Children and Youth Affairs allows 54 young people (to include a maximum of 48 boys and a maximum of

6 girls) to be accommodated at the campus.

The process of operational merger began in 2013 and was completed legally in June 2016. As such, it is a

very new campus with new management, a mix of new and merged staff and a broad range of young

offenders with multiple needs and vulnerabilities, and complex histories of persistent offending.

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THE REVIEW FINDINGS

We were struck by the clear, comprehensive and enthusiastic articulation of Oberstown’s current

philosophy, principles and developments as set out by the Director and Senior Managers with whom we

spoke, and we had the opportunity to see those being followed through within the weekly operational

Unit Managers management meeting we attended.

Findings and issues will be reported in the order listed by the review’s briefing terms. It should be

acknowledged that this is not necessarily the most natural structure to adopt for such a review but we

have used it here to enhance our recommendations in relation to the brief. Each domain is reported in

order and recommendations are listed at the end of the section and again at the end of the report. In

what follows, we separate our observations between written policies and procedures on the one hand

and their acceptance, understanding and practical implementation on the other hand.

RELIABILITY STATEMENT

One of the challenges of this review was to get to the ground truth (what is actually happening

on the ground) in order to cross reference and compare this with organisational policy and

statements. In order to do this, we used a mixture of information sources – documentation,

management and clinical data, CCTV recordings and interviews with staff and children. We applied

the principle of “triangulation” between different types of information and no quote has been

used unless it reflects what has been reported from at least two different sources.

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1. EARLY INTERVENTION APPROACHES

Oberstown is committed to working with young offenders in ways that are positive, evidence-based,

preventative and future focused. The approach to behaviour management is governed by a focus on

relationship building, a behaviour modification programmes (incentives) known as “levels” to the young

people and by Interventions organised to deliver best practice in Care, Education, Health and wellbeing

interventions, Offending behavior programmes and Preparation for Leaving (CEHOP).

The CEHOP framework, which is the organising tool for the young person’s journey through care at

Oberstown, is in our view a very appropriate and useful system. The management of inappropriate or

aggressive behaviour is overseen by staff. The staff have received training in the principles, practice and

use of Management of Actual and Potential Aggression (MAPA) methodology and strategies. In our view,

with one exception set out later, this is an appropriate approach with its emphasis on working with well

established relationships developed with the young people.

Young people we spoke to told us about “levels” and reported some practical challenges and in- built

injustices in the incentive system. Young people we spoke with were not familiar with CEHOP or

personal support planning and were critical of some staff‘s management of challenging behaviours on

the units. This is not unexpected given the nature of the context but perception is vital for behaviour

management and compliance and adherence with programmes of care.

Vision and values for the Campus were clear and appropriate but not consistently in evidence on the

Units. Whilst the Strategic Plan and Action Plan from January 2017 set an appropriate direction, these

should be made more explicit/visible and it is recommended that this should be remedied to facilitate

clarity of purpose as units are the young person’s albeit temporary home. Some of the new

developments and plans were not so clearly understood and/or accepted by other staff.

We were told by some senior and experienced staff that they had noted violations of basic procedures

that are not being tackled by unit managers, and that staff do not always know where unit managers

were; in our view, this requires management investigation which, if confirmed, should trigger remedial

actions.

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Amongst comments from some of the staff we interviewed were, “Every week something changes and

it’s difficult to keep up”; “Practice changes by memo without reference to the staff”. This we believe

may reflect a combination of (a) speedy developments (perhaps necessarily so?) with which some staff

had difficulty keeping up, (b) insufficient staff consultation (perhaps inevitable given the speed of

organisational changes?) and (c) some staff actively resisting the changes (through reasoned

disagreements or sometimes personal agendas regarding senior management).

We noted that some staff within the units were not familiar with, or signed up to the developments set

out by senior management, and we heard that the perception of some staff was that they were not

consulted or committed to these developments. Some staff commented, “Staff have solution but we’re

never asked”; “Give staff their head and show some respect”. It would be inaccurate to suggest that this

is a unanimous view as others spontaneously observed that some staff complaining about not being

informed / involved do not take opportunities to contribute when they are offered.

This heterogeneity of staff engagement or motivation is not easy to manage but may be ameliorated by

regular unit staff meetings and by signposting vision and values as part of a coherent and explicit

organisational framework, which is currently in train. We were told that proposals are in hand to have a

member of the team to act in a formal lead / coordination role in the absence of the unit manager. A

similar system had applied in the past on a voluntary basis but had ended with withdrawal of trade

union support at that time.

Overall, we were of the view that there is considerable experience which could be usefully tapped, both

for its own sake and as a mechanism for engaging all staff in working to a shared philosophy and

commitment to future developments. We were aware that not all staff held the same views and that

this suggests the existence of “sub-cultures” relating to issues of custody versus care and acceptance

versus suspicion of new initiatives. The legacy of different previous sub-cultures within Oberstown is

currently being addressed through a combination of strategic planning and practice development.

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RECOMMENDATION 1: The Vision and Values of the Oberstown campus, as reflected in the Strategic

Plan, should be embedded into all aspects of the routines and ethos of the facility for staff and young

people. Vision and Values should be displayed in all areas of care, education and living spaces and in a

welcome booklet should be given to each young person.

RECOMMENDATION 2: Introduce and embed risk, care and case management in Oberstown systems

and infrastructure, early from the point of admission right through to discharge.

Strengthen and develop CEHOP, the behaviour Incentive Scheme and MAPA by updating and reviewing

areas of concern.

In our view, MAPA is fit for purpose with the exception of its inability to manage the most extreme

forms of aggressive behaviour: the senior management team clarified for us that, in such extreme and

UPDATE: The implementation of CEHOP into practice is underway on a number of fronts. Direct engagement is taking place with staff through informational sessions, coaching and mentoring to ensure that the CEHOP model of care is being adhered to. Placement planning is an integral part of the CEHOP framework for the campus. There are written procedures for the operation of the placement planning process. A dedicated person had been allocated to chair placement planning meetings to achieve consistency in approach, engagement, attendance, recording and achieving agreed actions. A Young Person’s Programme Manager has been appointed to support the availability of a common approach to the young person’s care while on Campus. Rolled out in September 2018, the Oberstown Case Management System1 will support consistent record keeping on each young person. A restructuring of the management of residential units is currently being implemented, and it is envisaged that this new way of working will address outstanding issues regarding the implementation of policy and procedure into practice. From the moment young people come to Oberstown, they are given information in a youth-friendly manner and their needs are looked at in a holistic manner. Young people are encouraged to have input into their own Individual Crisis Management Plan (ICMP), which contains information about triggers, risks and how to best to deal with young people in crisis based on their own feedback.

UPDATE: The Oberstown mission, vision and values form part of the core message of the Oberstown Strategic Plan, 2017-2020, signed off on by the Board of Management in October 2017. The Strategic Plan was launched in December 2017. During the first quarter of 2018, information sessions were held across the campus to inform staff about the plan and its goals. Posters displaying the mission, vision and values are displayed throughout the campus and are included in the young person’s booklet in a youth-friendly manner. A report is currently (Oct 2018) being completed to measure progress achieved so far, and to plan for 2019.

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unusual situations, the Garda should be called via the Director or his representative, but this was not

understood or implemented in the experience of some of the staff we interviewed, and this should in

our view be clarified for staff, and confirmed by for all staff that they understand this and will act

accordingly.

Embedding sound behavioural management principles into practice could be enhanced by the use of an

already developed, tried and tested training / team building approach. Integrated Risk and Care

Programmes can be recommended if required. These systems should have value in integrating and

strengthening CEHOP, Behaviour Modification and MAPA and facilitate risk assessment and

prioritisation and the integration of risk and care.

2. ROUTINE PRACTICES

A significant contextual issue to the current review is clearly the coming together of three diverse

facilities, Trinity, Oberstown Boys and Oberstown Girls with Finglas Assessment Centre (FAC) to form the

current single campus / organisation (FAC was a separate entity at another location up until 2009). We

heard from many of those with whom we spoke how these units dealt not only with different groups of

children but, perhaps not unrelated, had different philosophies and practices underpinning the

children's care in their units. Explicit statement of vision and values publicly displayed in every unit

would be helpful here.

We also heard how some of these ideas and methods continue to influence the practice of those who

had previously worked in those units, and through them the junior staff they manage and supervise.

This, we were told, has led to some ‘conflicts of culture’, which have been played out in various

responses to management changes and organisational and practice developments, including issues

about best practice in behavioural management.

We were told by different interviewees that some staff’s stated dissatisfaction with current philosophy

and practice has resulted in challenge to new developments and practice; that some incidents have

been used by some staff to further this agenda; that some unit managers sometimes presented as “anti-

management” and needed to align themselves with the current direction of travel and manage their

staff accordingly; and that Standard operating procedures across campus are sometimes not being

implemented and / or are sometimes violated: for example, personal mobile phones being used, and

reported losses of, or turning down of radios. In our view, there is a need to ensure that basic operating

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procedures are in place as a safe and secure platform to provide proper care for the Oberstown

children, and that any confirmed shortcomings should be addressed.

RECOMMENDATION 3: Ensure that the behaviour management policy is supported by approved

and implemented operational procedures with supporting tools, including as effective records,

and appropriate training and supervision. Remedy missing, not used or switched off personal

alarms.

3. CRISIS RESPONSES

Oberstown’s explicit organisational framework for managing actual and potentially aggressive behaviors

is through implementation of MAPA up to and including situational application of disengagement and

holding skills and for rare challenges where that is insufficient that the Critical Incident Plan (contained

within the Business Continuity Plan 2016) is activated.

Behaviour management on campus supports, where necessary, the physical intervention by staff with

young people and two days of the five days training is evidence of this. However, we heard from a range

of staff and from the children themselves a number of consequences of lengthy times of resolution to

conflict by managing disruptive behaviour non-physically. The length of time that some incidents took to

resolve was said to be problematic (a) because it limited the activities of, and annoyed non-disruptive

children, and (b) encouraged some children to engage in similar (as they called it) ‘stand offs’ for

instrumental reasons (for example, gaining benefit) or expressive reasons (for example, excitement

seeking).

A review of operational procedures has been completed and full implementation of these procedures is in train. A programme of training for managers on supervision was completed in September 2017 and supervision for all staff is due to be fully implemented in 2019. A review of the Behaviour Management Policy will be completed before the end of 2018. The implementation of the case management system will support access by all staff to the relevant information including information relating to young people’s Individual Crisis Management Plan. The system will support planning and engagement with young people. Quarterly health and safety audits are carried out on all aspects of health and safety equipment and corrective actions are followed up and documented appropriately.

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One staff member said, “Boys will exploit weakness”. Another told us, “you can't put your hands-on kids

anymore” and that a boy had said to him, “If I don't touch you, you can't touch me”. Another said, “It is

not explained to the children what is happening to them, just simply letting children out after separation

and assuming the problem has been solved is wrong”. The possibility was raised that the full range of

MAPA strategies are not being used clearly, consistently or contingently on the Units. This emphasises the

need to keep MAPA training up to date and active for all staff.

It was clear to us throughout our visits and discussions that the organisation, staff in general and

some staff in particular had been significantly affected and traumatised by the aggressive

behaviours and criminal damage caused by eight boys to Units 1 and 2, culminating in the fire in

unit 3 in August 2016. We also heard from young people that some the children involved had

intended to burn down the whole campus, believing that this would lead to their exit from secure

conditions. We were assured by the Director that significant supports, internal and external and

engagement with staff has taken place about the incident in unit three over the past 12 months.

As well as the natural sense of shock that will occur after such events (described as the most

serious incidents on the campus since 1998), we heard that this event served to stimulate or

reinforce competing agendas on how care, and behavioural management in particular, are carried

out. Leaving aside comments on the events of August 2016, we heard diverse views about

behavioural management. However, no-one with whom we spoke varied from two conclusions:

One: non-physical methods should be the priority in managing behaviour (although opinions

varied on the extent to which this is sufficiently covered in primary and refresher training sessions,

and the extent to which staff were fully competent in and committed to this) and

Two: There are situations (very rare) that can arise for which the current behaviour management

methods cannot cope. Most staff spoke of this being an unresolved issue but we were advised by

senior management that, whilst there is a protocol for this, this issue is under current review.

Staff described a range of responses where children’s behaviour was more extreme than could be

managed by the current procedures. In these cases, we were told, for example, (a) that improvised

methods had been used in the absence of formal guidance, e.g. use of a mattress, (b) that staff had been

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injured by sticking to what they understood were the correct procedures, further indicating a need for

clear policy and practice guidelines, (c) that staff had contacting the Garda without senior management

approval. The current Critical Incident Procedure should, in our view, be disseminated and re-introduced

with chances for staff to discuss it and commit to its implementation.

We were informed by senior management that CCTV recordings of incidents are reviewed, and we had

the chance to review some of these ourselves. It was clear that these recordings could provide a useful

mechanism for learning, but there are HR policy limitations to this, which we believe could usefully be

reconsidered. The potential learning value of CCTV was endorsed by senior management and by some

of the staff we interviewed; however, it would be difficult to conduct cause analysis and learn lessons

without the benefit of sound on the CCTV capture. We understood that staff reviewing the CCTV

material of incidents in which they had been involved is not possible where disciplinary actions may be

taken.

RECOMMENDATION 4: Ensure use of full MAPA range of procedures and implement Critical Incident

Review Protocol with decision flowchart. Develop a Behaviour Management group to support the

review, development and implementation of behaviour management policy and procedures; invite

contributions from all staff groups across the campus, bring in opposing views, consult widely and

establish a revised behavioural management protocol with decision flowchart.

UPDATE: Consultation on the use of physical intervention was undertaken during 2018 with CPI/MAPA professionals and a schedule of training of MAPA for staff was undertaken and the training commenced in October 2017. A review of the Critical Incidents Protocol has been completed and training is underway with relevant staff. Consultation is also ongoing with staff representatives around approved responses to deal with challenging behaviour. However, Gardai continue to be available in incidents of significant concern.

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RECOMMENDATION 5: Establish a structure for the review and learning on incident management and

the monitoring of implementation of procedures and the utilisation of tools available.

This could initially be a quarterly campus-wide review and learning forum in which staff from across the

campus could be invited and encouraged to make presentations. Construct a behaviour management

checklist to facilitate good practice. Review what happened over that period, lessons learned, actions

taken, Showcase good practice examples of difficult situations handled well. Use this forum to design a

checklist for behavioural management: for use all the way around the child’s pathway through

Oberstown to identify desires, talents, activities, behaviours and cross checks for where failures are.

Best available evidence is that designing a checklist to help people handle complexity actually involves

more difficulty than generally understood. A well-constructed checklist will identify the moments in a

process when one can actually catch a problem before it is a danger and do something about it and help

to identify Antecedents, Behaviours and Consequences from pre-admission all the way through.

UPDATE: As part of the Campus health and safety requirements, each physical intervention where an injury occurs is reviewed and learnings are established. During 2019 a change in the policy on the use of CCTV is to be undertaken to allow CCTV be used as a learning and improvement tool.

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4. USE OF PHYSICAL INTERVENTION

Oberstown is a national facility for providing safe and secure environment for a diverse population of

young people under the age of eighteen who have been remanded or sentenced by the courts. It is

committed to incorporating only the most hopeful and helpful evidenced based policies and practice in

its campus. Relationship building is central to Oberstown’s prevention approach for working with

difficult or challenging behaviours.

We were told by senior managers that staff intervention through de-escalation and / or early physical

intervention may assist in reducing situations escalating. No-one however held to a view that non-

physical interventions, even given such skilled and proactive management, would prevent all instances

developing into situations requiring physical intervention.

It was suggested that, where the current physical intervention methods in MAPA are insufficient to deal

with a particular situation, ad-hoc responses had occurred, including: (a) withdrawing and letting the

situation develop uncontrolled, (b) innovating and improvising on methods of intervention or (c)

withdrawing and calling An Gardaí Siochana. We understood that the current Policy is to apply the last

of these, but that that this should only occur after consultation with the Director/Senior management.

However, we were told that the Gardai had previously been contacted without this approval. If correct,

this supports the need to re-emphasise the current policy.

RECOMMENDATION 6: Devote one meeting to review exceptional case scenarios and the contingency

plans in place to manage risks.

We suggest that this could be an open invitation across the campus, in one of the review meetings as set

out above.

UPDATE: Meetings are devoted to reviewing exceptional case scenarios and specific recommendations stemming from these reviews are implemented as part of the learning and improvement process. AIRS (After Incident Reviews) are routinely held for learning and prevention purposes. AIRS focus on policies, procedures and professional practices, which enables staff to process what happened, why it happened, and how to sustain strengths and work on areas of improvement. Peer Support Workers are also available to provide support to staff after a critical incident at work.

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5. USE OF THE ENVIRONMENT

We note that the behavioural management review we are undertaking runs in parallel with, and

interfaces with both the Security review and Health and Safety review.3 The whole campus and

built environment as well as the use of the Units, School and outside spaces are under review in

order to improve the use of the environment at Oberstown.

We understand from the records that many events and injuries occur between 6pm and 10pm

and that prevention strategies are currently under consideration to address this. For example,

injuries may relate to staff ‘winding down’ and not as aware of interpersonal issues in the

evening due to long shifts and some staff not willing to facilitate young people undertake

activities.

We understand from the records and from staff reports and comments that the Unit buildings,

fixtures and fittings (especially bedroom doors and locks) are a concern but management

responses are underway. The physical environment and culture, whilst of relevance in this

review, go to wider issues in the organisation and could usefully link with the other two Forde

reviews. Young people told us that there are a variety of activities available to them and that

these and school (10am- 3.15, with lunch break) is generally positive but that some evenings and

weekends are very long and boring and that sometimes “stand offs “are planned “just to get a

bit of excitement going.”

We were told by school staff that few incidents happen in school where the young people are

engaged and enjoy the activities, but it was not possible to validate this assertion. It was

separately suggested to us that greater use could be made of the school’s facilities and that

sessions do not run as long as they should. We also heard that this absence of full activity over

the allotted period was less to do with the school and more to do with unit management not

getting the children there on time. This may be useful for management to investigate and

remedy as needed. Comments made from the school and from some of the units were that

behavioural management is about “avoiding trouble, putting in place the plans and supports to

avoid it”; using a relationship model and “using the approach ‘what can I do to help you? - here

are your options.” worked best. This seemed to us to be a useful articulation of the ‘strategies of

choice’ method used within other secure services), and “treat them all like adults, be open and

honest with them”. “New staff and new teachers need to be mentored to develop skills”

3 In light of challenges experienced in Oberstown during 2016, several external expert reviews were undertaken to support the

development of Oberstown into the future. A Review Implementation Group was established in March 2017 to oversee the implementation of several reviews carried out in Oberstown during 2016/2017. All reports from the RIG available here

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RECOMMENDATION 7: Ensure the physical environment is safe and appropriate to meet

the needs of young people and staff.

Whilst this issue extends beyond behavioural management, it is nevertheless important to note it

here.

UPDATE: A planned enhancement of the physical environment of the campus began in 2017 and will be fully completed by the end of 2018. This series of measures has an allocated budget from the department of Children and Youth Affairs, and has improved the level of security of the built environment to ensure that the safety needs of staff and young people are met. Modifications to the secure zone of the campus have included additional lighting, fencing and other measures to ensure an awareness of and timely response to health and safety issues. Other refurbishments have included the upgrade of residential units, upgrade of new windows in remand units, new bedroom and office hatches, manual operation of the mist system and upgraded attic doors in the education building. All of these measures mean that Oberstown is a more robust environment, while at the same time ensuring that young people continue to live in a residential setting that takes cognisance of their needs.

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RECOMMENDATION 8: Review the provision of education and recreational programmes

and activities to achieve better outcomes for young people.

This will empower young people to develop personal support and development plans, life skills

and pro-social behaviours. An evidence based wellbeing programme could be used to strengthen

CEHOP and provide an approach to health and wellbeing, skill-building and rehabilitation and

provide a framework and tools for social, emotional and interpersonal skills that help people

interact effectively with their environment and other people.

6. MANAGING VIOLENT SITUATIONS

Oberstown’s formal approach to managing actual or potential aggression is through relationship

building and implementation of MAPA and where that is insufficient (in cases of violent or extreme

behaviours) that the Critical Incident Plan (contained within the Business Continuity Plan 2016) is

activated.

There was little evidence of staff use of the MAPA physical holding methods and there was a lack of

clarity and consistency in application of the 2016 Policy and procedures for managing extreme

situations. There was also little support from the staff that we interviewed for Personal Protection

Equipment (PPE) training, either for all staff or for a specially trained subgroup of staff.

Unlike interventions with adults, where physical control can be maintained by the pain experienced

from attempts to pull away from a hold, this is not an option for children. Everyone with whom we

spoke agreed that the most violent confrontations, involving for example threats with weapons to staff

or other children, could not be managed using the MAPA system. No- one suggested a solution apart

from calling the Gardai.

In our view, it may be more appropriate to have a team of dedicated staff trained and regularly

refreshed in PPE interventions available for those rare incidents where MAPA is insufficient, rather than

UPDATE: Education on the Campus is provided by the Department of Education through the Education and Training Board. An activities coordinator provides oversight by the Campus for recreational and educational programme outside of school hours. Further supports have been allocated to the activities coordinator since October 2017. The educational outcomes for young people are currently under consideration by a sub-committee of the Board of Management set up for this purpose. Engagement with the Department of Education regarding an education strategy has taken place. The Board of Management of Oberstown is currently in discussions with the campus school and its board with a view to a revised curriculum for 2019.

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having to turn to An Garda Siochana in all such instances. They may of course also be incidents which

would, in parallel or separately, require An Garda Siochana involvement. This PPE team could perhaps

have visits to other similar services to Oberstown as part of their CPD.

Two recommendations for MANAGING VIOLENT SITUATIONS have already been covered under

Recommendations 2 and 4 which are restated here.

RECOMMENDATION 2: Introduce and embed risk, care and case management in Oberstown systems and infrastructure, early from the point of admission right through to discharge

RECOMMENDATION 4: Ensure use of full MAPA range of procedures and implement Critical

Incident Review Protocol with decision flowchart.

These would provide evidence-based protocols for assessment, management, supervision, monitoring and audit. Good record keeping is essential for providing information, data and “intelligence” in risk management and for the prevention and management of violent and challenging behaviours.

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7. SAFETY FOR YOUNG PEOPLE AND STAFF

Oberstown has been engaged in an extensive process of change to enable safe and secure places for

young people in detention. Oberstown clearly recognises that it is vital that young people’s individual

needs are met and that while in detention every opportunity is taken to have a positive impact on their

lives. To this end, building relationships between young people and staff is explicitly referenced as a

major focus of the campus.

The Centre for Effective Services (CES) was commissioned in 2014 to help Oberstown to identify ways of

building effective relationships that can improve pro-social behaviours and outcomes for young people

in detention and the organisation is working on translating and implementing key strategies from this

research.

Children’s Admission, Induction and care planning:

We were advised by the Director that the development of the admission unit was established to

address a quality first point of contact for all young people coming on campus. The provision of

remand units to have this initial interaction has been a significant improvement since remand and

detention young people were separated.

Our impression from the young people and staff working with them with whom we spoke was is

that there is limited induction for the children, including setting out what will happen with them,

rules and procedures and how their behaviour will be managed. The key worker system is valued

by young people but individual care plans are not well developed or understood; and there was

little evidence of risk or care management plans. Incident reports provided some post hoc

explanations of events but there was limited evidence of shared learning from these. We

recommend that this is looked at and reviewed.

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Staff selection, training and supervision:

We were told of the importance of staff selection, induction, supervision and appraisal, and how some

staff who may not be up to the job could be removed during a probationary period, and that this could

and should happen, but did not always happen. We queried if removing unsuitable staff during the

probationary period would result in staffing problems, and we were assured by management that this

would not be an issue.

As well as the training, supervision, coaching/mentoring and support is required to ensure that staff

working with the children have the specific behavioural and psychological skills that are needed. We

were told by several of the longer-serving staff, that new or inexperienced staff need to see these skills

in action within joint working and to be assisted by mentoring. It was further suggested that senior staff

could be utilised in designing and operating mentoring on a more effective and comprehensive level

than is currently the case. This will build, support and harness the skills and commitment of skilled staff.

RECOMMENDATION 9: Enhance communication internally and externally considering all stakeholders

including young people and families.

This is implemented by “Walking the floor”, engagement (management processes working as intended),

Acknowledge and record young person’s skills, performance and progress, Acknowledge staff skills,

contributions and performance. Where possible and appropriate maintain and support contact with

families and involve primary healthy relationships in forward focus: this will help young people, their

families and significant others in connecting talk to action. Establishing and maintaining good quality

relationships between young people and staff and amongst peer groups of both young people and staff

can be used as a vehicle to enhance safety and overall programme quality.

The Oberstown Communications and Engagement Strategy was published in 2017. The document outlines the organisation’s plan for internal and external communications. Internally, Oberstown holds Town Hall meetings with staff and the Director operates an open door policy. Weekly communications meetings are held and the bulletins are sent out Campus wide. As part of increased transparency and external engagement in its activities, Oberstown held an event, Building the Future, in May 2017 to highlight its work advancing the rights of young people in detention in Ireland. In June 2017, Oberstown held a stakeholder event on the topic of substance abuse and mental health in young people in detention. The Oberstown website hosts a wide variety of content produced by Oberstown, including statistics, reports and press releases.

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RECOMMENDATION 10: Implement a wellbeing and performance programme for young people

and staff.

Programmes and interventions are more likely to have a positive impact when they are provided as part

of a coherent and explicit organisational framework. A health and wellbeing programme is

recommended as it would integrate well with current structures and it provides a framework and tools

for building life skills such as healthy thinking, positive emotions, engagement, relationship building,

meaningful purpose and accomplishment. Staff can be trained on the programme in such a way as they

can easily transfer it to their own lives and the lives of the young people in their care. Providing this kind

of health and wellbeing intervention and providing staff support and development will be important

elements in continuous improvement at Oberstown.

UPDATE: Care of young people on the Campus is currently based on best practice and a young person-cantered ethos, in line with the Children Act 2001. New routines and engagements are being developed to assist in the sharing of ideas and approaches between the School and the Residential Units. Young people have access to a range of programmes, delivered on site in Oberstown. Staff are also offered the opportunity to upskill in a variety of ways. A programme of work was completed during 2017 & 2018 in the support of staff well-being, involving peer support training, availability of an on-site organisational psychologist, an employment assistance programme and an occupational health service. A mental health & well-being booklet is currently been printed for all staff in order to promote health & well-being throughout the organisation and support staff in need of assistance. STORM1 training was also rolled out across the Campus during 2018. A review of the clinical services available to young people on site was initiated in September 2017 with the support of TUSLA and the HSE and psychological and psychiatric services are now available on-site.

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RECOMMENDATIONS SUMMARISED

RECOMMENDATION 1: The Vision and Values of the Oberstown campus, as reflected in the

Strategic Plan, should be embedded into all aspects of the routines and ethos of the facility

for staff and young people.

RECOMMENDATION 2: Introduce and embed risk, care and case management in Oberstown

systems and infrastructure, early from the point of admission right through to discharge.

RECOMMENDATION 3: Ensure that the behaviour management policy is supported by

approved and implemented operational procedures with supporting tools, including as

effective records, and appropriate training and supervision. Remedy missing, not used

or switched off Conex.

RECOMMENDATION 4: Ensure use of full MAPA range of procedures and implement

Critical Incident Review Protocol with decision flowchart.

RECOMMENDATION 5: Establish a structure for the review and learning on incident

management and the monitoring of implementation of procedures and the utilisation

of tools available.

RECOMMENDATION 6: Devote one meeting to review exceptional case scenarios and

the contingency plans in place to manage risks.

RECOMMENDATION 7: Ensure the physical environment is safe and appropriate to meet

the needs of young people and staff.

RECOMMENDATION 8: Review the provision of education and recreational programmes

and activities to achieve better outcomes for young people.

RECOMMENDATION 9: Enhance communication internally and externally considering

all stakeholders including young people and families.

RECOMMENDATION 10: Implement a wellbeing and performance programme for young

people and staff

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